case 2 roque -simbulan. history pertinent findings
TRANSCRIPT
History of Present Illness 7 days PTA On and off fever, Tmax 39oC
temporarily relieved after intake of Paracetamol. 6 days PTA Appearance of maculopapular
rashes at the head progressing to the abdomen and to the extremities. Fever persisted.
5 days PTA Dry fissured lips. Rashes and fever persisted.
History of Present Illness 4 days PTA Signs and symptoms persisted. 3 days PTA Patient was brought to Immaculate
Concepcion Hospital in San Pablo, Laguna. Assesment was T/C Systemic Viral Infection and was given Co-trimoxazole, Paracetamol, and ascorbic acid. Mother noted edema of the finger tips and desquamation of the skin at the buttocks area with persistence of fever. Hence, transferred to PGH and subsequently admitted.
Review of Systems
(-) abdominal pain, (-) seizure, (-) chest pain,
(-) diarrhea, (-) cough, (-) nausea, (-) colds,
(-) vomiting, (-) conjunctival suffusion
Birth and Maternal History
Born FT to a then 24 year old G2P1(1001) mother via SVD delivered at home by a midwife. Mother had regular PNCU c/o local health center with intake of MVT and FeSO4. No fetomaternal complications.
Personal and Social History
Mother is a 26 year old housewife. Father is a 28 year old security guard. Patient is the second child in a family of 2
kids. Older child is 5 y/o male, healthy.
IMMUNIZATION HISTORYThe patient has the ff. : The ff. are expected:
(+) BCG
(+) OPV3
(+) DPT3
(+) Hepa B3
(+) Measles
Birth: BCG, Hepa B
6 weeks: DPT1, OPV1, Hepa B
10 weeks: DPT2, OPV2, (Hepa B*)
14 weeks: DPT3, OPV3, Hepa B
6 months (and yearly thereafter): Influenza
9 months: measles
12 months: MMR, Varicella, Hepa A (2 doses 6 months apart)
Recommended Immunizations
The patient should also be getting yearly Influenza shots, as well as MMR, Varicella, and Hepa A shots.
MMR should be taken at 12 mos; the 2nd dose should be taken through 4-6 years (can be taken before 4 mos, provided at least 28 days have elapsed since the 1st dose)
Recommended Immunizations
Varicella: min age is 12 mos; 2nd dose should be taken from 4-6 yrs (can be taken before 4 yrs provided at least 3 mos have elapsed); min interval bet doses is 3 mos for children aged 12 mos to 12 years
Hepa A: min age is 12 mos; administer 2 doses at least 6 mos apart
Nutritional Status
Patient History WHO Recommendation
Breastfed for 6 months Exclusive breastfeeding for 6 months, followed by continued breastfeeding w/
complementary food up to 2 yrs
Shifted to milk formula at 6 months, consumes 4 ounces/feeding every 3
hours (900 ml/day)
At 6-12 months and without other animal food sources, milk formula intake should be 400-550 ml/day
Semi-solid food started at 9 months Semi-solid food started at 6 months
Presently eats table food Table food permitted at 12 months
*Patient’s weight (10kg) is less than the 5th percentile for her age. Diet needs to be improved and growth further monitored. (source: Nelson’s)
The patient is at par with her age (2 years old)
Developmental milestones of a 2 year old child:Physical Development-Child reaches about ½ of his maximum adult height.-90% of adult head circumference is reached, with just an additional of 5 cm gain for the next few years.Motor Development:-Runs well-walks up and down the stairs, one step at a time-climbs on furnitures-jumps
Adaptive Development
-Makes tower of 7 cubes
-Scribbles in circular pattern
-Imitates horizontal strokes
-Folds paper once, imitatively
Cognitive Development-Object permanence
-Improved problem solving skills, better understands cause and effect
-Language: -Puts 3 words together into simple sentences (subject, verb, object)
-Vocabulary comprises of about 50-100 words
-Can understand and follow 2-step commands
Socio-Emotional Development-Often tells about his immediate experiences
-self awareness and internalized standards of behavior sfirst appears at this age
Self-Help Skills
-Handles spoon well
-Helps in undressingSource: Nelson Textbook of Pediatrics
Awake, not in cardio-respiratory distressWt 10kg Ht 91 cmBP 90/60 HR 11 RR 20 T
38.3oCPink conjunctivae, anicteric sclerae, no eye
discharge, hyperemic tonsillopharyngeal walls, (+) CLAD, left >1.5 cm, dry cracked lips
Adynamic precordium, distinct heart sounds, tachycardic, regular rhythm, (-) murmur
Equal chest expansion, clear breath sounds, (-) crackles, wheezes, retractions
Abdomen flat, soft, (-) tenderness, normoactive bowel sounds, (-) hepatosplenomegaly
Pink nailbeds, full pulses, (-) cyanosis, (+) edematous finger tips, (+) sacral desquamation, (+) generalized maculopapular rashes
Normal external genitalia
KAWASAKI DISEASE
RULE IN LESS LIKELY BECAUSE
(+) fever ≥ 5 days, persistently high, despite medication(+) hyperemic tonsillopharyngeal walls(+) unilateral (left) cervical lymph adenopathy, >1.5cm(+) edema of extremities(+) dry fissured lips(+) maculopapular rash(+) desquamation in the sacral area with rash(+) tachycardia
(-) conjunctivitis
SCARLET FEVER
RULE IN LESS LIKELY BECAUSE
(+) fever(+) rash w/c appeared a day after fever and which spread from the head abdomen and extremities (+) desquamation
Persistence of rash
MEASLES
RULE IN LESS LIKELY BECAUSE
(+) fever(+) maculopapular rash head abdomen & extremities(+) desquamation
(+) Measles Vaccination Rash appeared a day after fever (-) cough(-) coryza(-) conjunctivitis(-) Koplik spots
RUBELLA
RULE IN LESS LIKELY BECAUSE
(+) maculopapular rash head abdomen & extremities(+) cervical lymph adenopathy
(+) fever (+) desquamationRash persisted > 3 days
INFECTIOUS MONONUCLEOSIS
RULE IN LESS LIKELY BECAUSE
(+) fever(+) hyperemic tonsillopharyngeal walls(+) cervical lymph adenopathy
(-) hepatosplenomegaly
ROSEOLA
RULE IN LESS LIKELY BECAUSE
Acute Presentation of fever
(+) CLAD
Likely for the Px’s age group
Facial sparing of the rash in roseola Patient’s fever is persistent and is less than 39oC
TOXIC SHOCK SYNDROME
RULE IN LESS LIKELY BECAUSE
(+) acute fever > 38.9°C(+) progressive rash: generalized maculopapular(+) hypotension : BP less than 5% 2 y/o(+) oropharyngeal hyperemia
Desquamation in the sacral area started 4 days after onset [ TSS desquamation occurs 1-2 weeks after onset, particularly palms and soles](-) vomiting(-) diarrhea(-) conjunctivitis(-) focal Staphylococcal infectionMucous membranes usually sparedRashes usually present as bullous impetigo, scarlantiform lesions or diffuse erythema
The ff. diagnostic procedures can be done to make a more definite diagnosis and rule out differentials:
( tests and expected results) CBC
In measles: Leukopenia; Normal ESR/CRP In roseola: Leukopenia In KD: WBC normal or elevated, predominantly neutrophils; platelet normal
in wk 1, elevated in wk 2-3, elevated ESR and CRP
Renal/Hepatic Tests In toxic shock syndrome: Elevated AST, ALT , or creatinine (>2x)
Serology Rubella: (+) rubella IgM antibodies Roseola: (+) roseola specific antibodies
Antibiotic therapy Scarlet fever: rapid clinical response (24-48 hr)
PERTINENT LABORATORY FINDINGSLABORATORY FINDING COMMENT
WBC = 20.20 with Seg 0.667
LEUKOCYTOSIS WITH NEUTORPHIL PREDOMINANCE (LEFT SHIFT)Rules in Kawasaki DiseaseRules out Measles and Rubella
Plt 346 PLATECOUNT WITHIN NORMAL RANGE BUT HIGHRules in Kawasaki DiseaseRules out Toxic Shock Syndrome
CRP > 12ESR QNS
ELEVATED CRP & ESRRules in Kawasaki DiseaseRules out Measles
Hgb 100Hct 0.31
ANEMIA Rules in Kawasaki Disease
2d Echo: Dilated Right Coronary Artery
IMPENDING SIGN OF RCA ANEURYSM Rules in Kawasaki Disease
Diagnostics
There is no diagnostic test for Kawasaki disease, but certain laboratory findings are characteristic.
Normal to elevated WBC; predominance of neutrophils Elevated ESR and CRP Normocytic, normochromic anemia is common Platelet count normal during 1st week, increases by 2nd
- 3rd week
Patient’s Lab resultsCBC Results Normal
ValuesRemarks
HgB 100 90-140 g/L Normal
Hct 0.31 0.28-0.42 Normal
WBC 20.20 6-17.5 x 109 Elevated
Seg
0.667 0.54-0.62 Elevated
Plt 346 150-400 Normal
CRP >12 0.8-7.9 Elevated
ESR QNS 0-10 mm/hr ---
Patient’s Lab results Urinalysis: Normal except for slightly hazy
appearanceSterile pyuria may be present in KD
Chest X-Ray: No significant chest findings 2d echo: Dilated Right Coronary Artery, Trace
PR, good biventricular contractilityCardiac involvement is the most important manifestation
of KD Blood CS: No growth after 2 days
Other possible diagnostic tests:
Other characteristic laboratory findings of KD:
(-) Antinuclear antibody (-) Rheumatoid Factor Mild elevations of the hepatic transaminases
and CSF pleocytosis may be present
Natural History of the Disease
It is childhood vasculitis manifests with fever and a blanching rash. Most cases occur in children < 5 years although children aged 2 years are most commonly affected.
The most serious complication of Kawasaki disease is coronary artery aneurysm secondary to the acute coronary arteritis. Intravenous immunoglobulin and aspirin therapy given within the first 10 days of the illness can decrease the risk.
Pathophysiology
Etiology is unknown however it is commonly related to a staph,strep or systemic viral infection
Inflammation due to previous infection causes intimal proliferation and infiltration of vessel wall with mononuclear cells causing vasculitis
TREATMENT High dose IV gammaglobulins
- treatment of choice for Kawasaki disease- administered as a single bolus of 2 g/kg or as a 400-mg/kg infusion daily for 4 days- most effective in preventing development of coronary artery aneurysm when used within the first seven days of onset of fever
Aspirin - used together with IV gammaglobulin
- administered at a dose of 80-100 mg/kg/day for the first 2 weeks - administration is continued until fever subsides, after which a lose dose of 3-
5mg/kg/day is continued for 6-8 weeks or until there are no more signs of coronary artery disease
Anti inflammatory drugs- for pain management
Other Options- Plasmapheresis- TNF-blocking drugs to minimize inflammation- Steroids for those who failed to respond to initial treatment
Treatment for Complications
1. Coronary Artery Disease- Aspirin and dipyridamole- Anticoagulatant therapy- Fibrinolytic therapy- Surgical management- Interventional Cardiac Catheterization Techniques
2. Chronic Myocardial Ischemia- Transluminal coronary angioplasty- Coronary artery bypass-graft surgery- Cardiac transplantation
3. Pneumonia - amantadine, rimantadine, osetamivir
Non Pharmacological Treatment
Since the exact cause of Kawasaki disease is not yet fully understood, there are still no known preventive measures for the disease
Treatment is generally safe and effective
Education on early treatment is important to prevent further complications
Management
Further Outpatient Care careful follow up for cardiac complications
(CAD) pediatric cardiologist long-term implications for coronary artery
disease are unknown at this time.
Management
Deterrence/Prevention unknown etiology, no method of
deterrence. Therapy is directed at prevention of coronary artery aneurysm formation.